Causes of Neck Pain and Headaches
It is well recognized that specific incidents may trigger acute neck pain or headaches, and these will be obvious to the patient. However, it is also common for these symptoms to arise gradually from no obvious cause. In these cases, it is likely that there are a number of contributing factors and a self-perpetuating cycle responsible for the persistence of symptoms. An accurate diagnosis is required to identify these various factors. This may involve using diagnostic anesthetic blocks to try and eliminate one of the possible pain-generating structures in those patients who do not respond to treatment. An accurate diagnosis will also help to identify those rare cases with serious pathology from the more common mechanical neck disorders.
Neck pain and headaches are global problems with huge social and economic costs. Because these problems are so pervasive, it is important to identify and address the various causes that may be contributing to the patient’s symptoms. This is particularly important in those patients with chronic or recurrent symptoms. By identifying the causes of a patient’s neck pain and/or headache, there is a greater chance of providing a more specific and effective treatment strategy.
Common causes
Any structure, whether a high-rise building or an individual’s spinal column, is vulnerable to damage or injury. Activities such as lifting, carrying, and prolonged sitting can cause abnormal stress to be placed on the bones, joints, and muscles of the spinal column. Neck pain can result. Injuries ranging from a mild neck strain to a more serious injury such as whiplash can cause the soft tissue of the neck to become inflamed. Inflammation of the neck ligaments and/or the muscles of the neck and shoulders can cause significant pain or discomfort. In some cases, pain resulting from inflammation is not immediate and may not present until some hours or days later. Persistent or recurrent episodes of acute inflammation can lead to a chronic painful condition. Patients presenting with chronic neck pain of this nature will often state that they do not recall a specific incident but will generally point out that their pain began at a time in their life when they were experiencing unusual or unexpected levels of stress or were involved in an unusually strenuous or prolonged activity. Women, in particular, have a higher likelihood of suffering from neck pain due to stress and/or muscle tension at work, in the home, or during recreational activities. This is likely due to a higher incidence of mental health conditions such as anxiety or depression, which has been associated with increased muscle tension and psychological stress.
Role of poor posture
Although poor posture may be almost self-explanatory, kyphotic and military posture has been found to be significantly related to an increased risk of developing chronic neck pain. Kyphotic posture exaggerates the thoracic curve and forward head posture, while military posture involves cervical extension and decreased mobility. A study by Griegel-Morris et al. has found that the specific combination of increased thoracic and cervical curve was a risk factor for the onset of chronic neck pain and headaches. This is likely due to increased muscular effort to maintain this posture and increased compressive force on the zygapophyseal joints in the cervical spine. Overall, it is evident that posture has a significant impact on the loading of the cervical spine and can lead to chronic pain if the posture is maintained for prolonged periods.
Neck pain and headaches due to tension are affecting an increasing number of individuals. This may be due to a number of psychological and physical stressors that result in abnormal pressure on the neck and shoulders. There are four types of stress related to neck and shoulder pain. These include: emotional stress that can produce tension in the muscles and cause the muscles to become fatigued, postural stress from maintaining poor posture in sitting or standing, muscle overload from occupational or recreational activities, and inactivity where prolonged rest or sleep may result in abnormal static load on the neck.
Impact of muscle tension
Muscle tension headache is a common type of headache which is especially related to stress, tension, and an abnormal posture. In particular, a common scenario is a person who is under stress and has tension in the muscles at the back of the neck. This can cause neck pain. The combination of neck pain and headache caused by muscle tension is so common that some researchers believe the two conditions are two aspects of the same condition. For example, a study published in the international journal Cephalalgia reported the findings of researchers at the Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK. They found that patients with chronic post-traumatic headache after a mild head injury usually also have chronic pain in other body regions and musculoskeletal complaints. And, these are scientifically recognized as chronic post-traumatic headache is a chronic headache which develops after a head injury or the headache persisting since the head injury. The muscle tenderness and myofascial trigger points are the symptoms which distinguish these patients from patients with chronic tension-type headache.
Many people hold stress and tension in their neck and shoulder muscles, often in response to the tensions and stresses of everyday life. This muscle tension can cause episodes of neck pain and headaches. For some people, the pain and discomfort are mild and occasional. For others, the pain is continuous and can be quite severe. This can lead to a decrease in activity level, disturbed sleep, and depression.
Non-Invasive Treatment Methods
If the physical examination and patient history suggest that there is a mechanical cause for the pain, then physical therapy involving active and passive treatments may be prescribed. Examples of passive treatments are heat/ice, TENS, iontophoresis, phonophoresis, and ultrasound. These are done to the patient and are not done by the patient. Heat is used to dilate blood vessels, increase blood flow, and relax muscles. Ice is used to constrict the blood vessels, decrease blood flow, and decrease pain and muscle spasms. The best rule of thumb is to use ice the first 24-72 hours and then switch to heat. The TENS unit has been found to be quite effective in the management of chronic (long-term) pain. Electrodes are placed on the skin and the unit sends small electrical currents into the nervous system in an attempt to change pain perception. This is achieved by closing the pain “gates” in the nervous system. A study done by Khadilkar et al on the use of iontophoresis and phonophoresis has shown that there is added benefit to using a steroid solution in iontophoresis for pain relief of cervical radiculopathy. This, of course, would have to be further looked into to decide long-term benefits and so on cervical radiculopathy. The ultrasound is often used in deep heating of tissues and joints, increases tissue extensibility, and can increase the rate of myofascial repair and remodeling. Once again, all of these treatments have shown benefits for many different kinds of neck pain, but evidence-based research is fast becoming a crucial factor in deciding what treatments are used in specific mechanical neck pain conditions.
Physical therapy exercises
A recent systematic review by Monticone et al. explored the effectiveness of a specific exercise, one type of manual therapy, and one type of physical therapy compared with advice to stay active in patients with sub-acute and chronic neck pain. Seven randomized controlled trials were identified, and methodological quality ranged from low to moderate. The review showed strong evidence that a specific exercise is more effective than general exercises in reducing pain, improving function, and quality of life in the short-term and long-term for patients with chronic neck pain.
Physical therapy encompasses a variety of exercises and techniques designed to restore function to the body, improve quality of life, and enhance overall well-being. A study by Kay et al. investigated the effectiveness of physical therapy on patients with chronic neck pain via a randomized control trial. Results showed that group exercise was more beneficial than routine primary care in regard to global outcome and pain. Individual exercise was more effective in reducing pain than manual therapy. The study suggests that multimodal approaches using a combination of exercise techniques are effective in reducing pain and improving quality of life in patients with chronic neck pain.
Heat and cold therapy
Patients with chronic pain can usually benefit from therapeutic science that involves heat or cold. The use of heat or cold can be an easy, self-directed kind of self-care that can be helpful to a patient’s ability to tolerate activity or exercise. Heat dilates the blood vessels, stimulating blood flow, and inhibits the pain messages sent to the brain. There are 2 ways to apply heat to areas which can be a treatment for neck pain causing headaches. Dry heat (e.g., heating pad or heat wraps) may be used for 20-minute treatments at a time a couple of times a day. Moist heat (e.g., hot packs, steamed towels) is even more effective, as it provides deeper penetration. This can be done with a hot shower or a commercial heat pack which is heated in a microwave. Commercial products can provide low-level heat for several hours and are especially useful at bedtime. It is extremely important not to burn the skin, which can lead to further complications. Heating products should be used conservatively and should never be used while sleeping. Moist heat is especially useful in the treatment of chronic pain. Heat therapy can be used to relieve chronic ongoing pain due to overuse injuries. An example is postural stress which occurs from holding the head in one position for a long time. This triggers muscle tension that can be relieved by heat, relaxation, and a common trigger point of occipital headaches can be alleviated. Cold therapy is used to relieve pain and swelling. It is especially effective for reducing inflammation and is one of the most effective self-care treatments for an acute neck injury. This includes recent onset of pain or a new injury. A recent onset of neck pain is often related to some form of minor trauma, usually a frequent cause is bending forward and then backwards with a sudden twist to one side. In medically treating an injury, cryotherapy (cold therapy) is considered the modality of choice, to reduce blood clot formation and the spread of inflammation. A recent onset of neck pain can be quite severe; in these cases, it can be useful to apply a cold pack for pain relief, 10 minutes at a time several times a day. This may prevent further spread of inflammation and pain to the shoulders or upper back.
Massage therapy
The greatest benefits of massage therapy are for those patients that suffer from chronic muscle tension in the neck and upper back. Tension type headaches are also a main result of muscle strains, and massage can be effective at relieving headaches especially when combined with other treatments. Overall, massage therapy is a low-cost treatment with few side effects and a good option for patients with chronic neck pain.
A comparison of the massage group to the group receiving routine medical care showed that the group receiving massage had significant improvements in the SF-36 bodily pain and physical role functioning scale. The group also showed a trend toward lessening days in pain and general health improvements. In a second trial, participants were randomly assigned to receive various levels of dose and types of massage therapy over a 10 week period or usual care. At the 4 and 10 week mark they reported significant changes in the Northwick Park Questionnaire and measurements of mental stress.
Massage therapy is a treatment often recommended for patients with neck pain. Specially designed clinical trials have found that massage can be quite effective for the relief of chronic neck pain. In the first trial, the massage group received treatments that were 30 minutes long for 4 weeks. All of the patients received both a Swedish and a trigger point massage and were also taught posture education which consisted of the proper way to perform a sitting desk activity.
Chiropractic adjustments
Defined as “manipulation of the spine to correct ‘subluxations'”, 68 chiropractors performed 6365 cervical manipulation treatments on 3455 patients. Approximately 11% of these procedures resulted in some form of aggravation or ‘adverse effect’ in the patient. It was found that the normal course of events following these adverse effects were: the exacerbation of the patient’s symptoms for 24 hours, which then spontaneously resolved. This sequence of events was reported by 80% of the patients. In understanding an adverse effect to mean ‘a change for the worse’, the fact that the patients’ symptoms increased and then spontaneously resolved means that the patients’ symptoms changed, but not necessarily for the worse. This report does not state the nature of these ‘changes for the worse’ and how long before the resolution, the remaining 20% of the patients experienced them. The incidence of more significant complications from cervical spine manipulation is fortunately very rare and difficult to document. One method of standardizing and grading the range of complications of an intervention into a particular therapeutic area is the use of a commonly used tool known as the NCM grading system. This grading system uses a combination of verb and noun ascriptions to qualify the severity of each event. An example of this would be a ‘mild transient adverse effect’, where the verb denotes the duration, onset, and course of the event and the noun qualifies its significance. Using this classification, a systematic review of prospective studies in primary care and secondary care settings of the UK suggests that the overall rate of minor adverse effects of spinal manipulative therapy (SMT) to be between 33% to 60% and the rate of serious adverse effects was thought to be no more than one in 400,000. In comparison to the cervical SMT adverse rate portrayed by the previous best evidence review, the severity of the adverse events documented were not explicitly specified; however, given what was said of their incidence, it is likely that they were classifiable. Chiropractic treatment is deemed to be a low-cost, manual therapy that has beneficial effects on back and neck pain.
Medication and Interventional Treatments
Over-the-counter pain relievers
These are medications that can be obtained without a neck pain treatment doctor‘s prescription. Their efficacy in treating neck pain and associated headaches varies. Drugs such as aspirin, ibuprofen (i.e. Nurofen), naproxen (i.e. Aleve) are all anti-inflammatory medications. They are generally more effective for neck pain and headaches associated with neck pain as opposed to headaches. Acetaminophen (i.e. Panadol) is a simple painkiller that has minimal effects on inflammatory pain. It is less effective for neck and arm pain with a herniated disk. Combination drugs such as aspirin with codeine or acetaminophen with oxycodone are more powerful and are more effective for headaches and migraines that are more severe. Hofbauer et al compared aspirin (acetylsalicylic acid), acetaminophen, and caffeine with sumatriptan. They found the former medication to be as effective as sumatriptan for migraine. [28] Side effects of NSAIDs can include gastrointestinal upset, peptic ulcers, and impact on renal function. It is wise for patients to discuss the usage of NSAIDs with their doctor or pharmacist, particularly if they are elderly or have other significant medical problems. Recommended doses of OTC medications for neck pain and headache can be found in Table III.
Prescription medications
Migraine headache has a clearer medication correlation. The abundance of literature on various migraine headache pathophysiologies has brought forth many different types of migraine specific medications. These range from older ergotamine derivatives to newer triptan agents and recently developed preventive medications which can be highly effective but are often underused. Randomised controlled trials on neck pain and cervicogenic headache are lacking and evidence on the use of migraine medication for these conditions is anecdotal. However, the author has found common use of nortriptyline to be effective in patients with chronic neck pain and coexisting cervicogenic headache. This may be related to the known efficacy of tricyclic antidepressants for cervicogenic headache and suggests that a systematic assessment of medication type related to neck pain and headache is warranted.
Since there are several different types of headaches, it’s helpful to be informed on the type of headache one has, and which medications are best for that specific type. A tension headache usually responds to muscle relaxants, tricyclic antidepressants and/or anti-anxiety agents though use of the latter carries the risk of dependency. Tension headache has been known to respond to tricyclic antidepressants in low doses. If tension headache evolves into chronic daily headache, a known cause of chronic neck pain and aggravator of already existing neck pain, use of migraine preventative medication would also be indicated as chronic daily headache is now considered a form of chronic migraine. This direct link between tension headache and chronic daily headache and neck pain to various types of headache and a clear medication cause makes accurate diagnosis of headache type a vital part of treatment. High dose antidepressants and antiepileptic drugs are also effective for chronic daily headache and in particularly severe or debilitating cases a short term trial of oral corticosteroids can be given, albeit with caution due to the risk of side effects.
Prescription medication is a way to reduce headaches and chronic neck pain. Namely, prescription medication can aid with tension headache relief. When used in combination with physical therapy, there is a higher chance that the headache or neck pain sufferer will have a reduction in headache and neck pain symptoms. Once the cause of the headache and/or neck pain is diagnosed, the most effective treatment method can be chosen.
Trigger point injections
Trigger points are focal, irritable points located in a taut band of skeletal muscle. These can be tender to the touch and often refer pain to other areas. Trigger point injections have been found to be an effective form of treatment. In a study by Naylor et al., 39 patients with myofascial pain were randomly allocated into 2 groups. The treatment group received injections of lidocaine into trigger points, the control group received sham injections of saline. All patients were also given instructions on stretching exercises. The treatment group’s average pain over the last 7 days, as measured by the McGill Pain Questionnaire, was significantly lower than the control group at both 1 and 3 months after injections. At both these times, the treatment group also reported a significant decrease in the number of pain areas compared to the control group. The treatment group also showed a significant decrease in worst pain over the last 7 days compared to the control group at 1 month after injections. A report by Rannou et al. demonstrated the advantages of using steroids in trigger point injections. 67 patients with cervicobrachial pain were randomly given injections into painful upper trapezius areas with either steroids, anesthetic, or placebo. The steroid group had significantly less pain and better mobility than the other groups at both 1 and 4 weeks. Though trigger point injections are helpful, there are conflicting beliefs about how to best perform the injection. Hong has stated that the most widely used needling technique is “wet needling,” which involves inserting a needle into the trigger point then aspirating and re-injecting the medication. He argued that this increased the probability of complications and most likely did not hit the actual trigger point. Hong recommended inserting the needle until it hit the trigger point then injecting the medication only. This dry needling technique was also recommended by Simons and Travell in their report on the topic.
Nerve blocks
Nerve blocks are used to anesthetize a specific nerve that is believed to be causing the neck pain or headaches. The purpose is to reduce swelling and inflammation around the nerve and also to “turn off” the pain signals coming from the nerve. If the nerve block is effective, then the anesthetic agent that was injected will reduce the pain for a few hours. While the anesthetic is working, it is expected that the patient will engage in normal physical activities that would otherwise be painful. If the patient finds that the anesthetic was helpful, then a series of injections can be made around the nerve using an agent that will produce a longer lasting effect. This agent is often a corticosteroid. Corticosteroids are powerful anti-inflammatory agents. Corticosteroid nerve blocks are generally very effective and can provide long-term pain relief. However, corticosteroids should not be injected intravascularly or administered more than about three times in a given year. High dose or long-term use of corticosteroids may have adverse effects. There is another type of nerve block which is used to treat headaches located in the back of the head. The nerves at the base of the skull can be injected with a local anesthetic or corticosteroid. This can be done in a process called a sphenopalatine ganglion block or an occipital nerve block. This can be very effective in reducing or eliminating chronic headache and migraine pain.
Lifestyle Changes for Long-Term Relief
Ongoing stress can contribute to neck pain and headaches. Stress is a large part of everyday life, affecting how we feel, think, and our behavior. Most people will have experienced some sort of tension headache caused by stress. The body responds to stress by increasing tension in the muscles, particularly in the shoulders and neck. This increased muscle tension can cause irritation of the nerves in the neck and can cause a headache. Identifying what factor in the work environment or at home is causing the stress will help to find a solution. Stress management techniques such as deep breathing exercises, meditation or yoga are ways of r
Maintaining long-term relief and preventing recurrences of neck pain and headaches can be achieved through lifestyle changes. The most common is making ergonomic adjustments. If you spend a large amount of time sitting, in front of a computer, ensure that your workstation is ergonomically correct. This will help to reduce chronic postural stress on your neck and shoulders. Even if you do not have a desk job, you can improve your comfort while watching TV or reading. Sit in a supportive chair. Proper sitting can also avoid a lot of pain. Sit upright with your head aligned with your shoulders, rather than stooped forward. Avoid slouching. Use a chair with good lower back support. Change or move your position every 30 minutes.
Ergonomic adjustments at work
Neck pain and headache can both be the result of mechanical overload from poor posture or ergonomics. Long hours in front of the computer, poor desk and chair configuration, and low stress tolerance can build up muscular tension in the neck and can cause cervicogenic headache. Poor ergonomic design of computer workstations is a common contributory factor for developing neck pain. For most desk workers, it’s not feasible to change the whole workstation; however, some simple modifications can have a significant effect. Ensure that the monitor is at eye level and directly in front of you to avoid twisting the neck. Sit upright with the low back supported by the chair; a rolled-up towel can be used to support the inward curve of the low back. Armrests will help support the weight of the arms, taking load off the upper traps and shoulder muscles. Ensure that the chair height allows the feet to rest flat on the floor; otherwise, use a footstool. Frequent short breaks should be taken to stand up, stretch, and walk around. During phone use, a headset or speakerphone is preferable to avoid cradling the phone between the ear and shoulder. A study conducted in the Netherlands has shown that prospective memory and neck pain significantly improved after a 6-week ergonomic training program in a group of younger office workers. This demonstrates how well these ergonomic principles can benefit those with neck pain and headache, particularly for preventing symptoms from becoming chronic.
Stress management techniques
Stress management is a key aspect in the treatment of neck pain and headaches. An increase in stress levels has been directly correlated with increases in reported cases of headaches. As a result, those with high levels of stress may experience a worsening in symptoms of both neck pain and headaches. This is particularly relevant in the working environment. Stress management may come in many forms and is often easily said and done; however, there are a number of simple measures that can be taken to reduce stress and thus reduce symptoms. This may be through changes in workload or environments, psychotherapy, or other forms of counseling. Biofeedback has also been suggested for patients with tension headaches. This is where an electrical sensor is connected to the skin and it monitors muscle tension. The feedback is then given back to the patient, in which they can then learn to control their muscle tension, thus reducing the stress that has accumulated. This has been shown to alleviate headaches in some patients.
Regular exercise and stretching routines
Lifestyle changes for long-term relief Regular exercise and stretching programs have been recommended as an integral part of the treatment of chronic neck pain and headaches. These programs are designed to prevent the deconditioning of the body, which is known to lead to further injury and pain. It is a common belief that regular exercise can help to relieve the symptoms of neck pain and headaches in both the short and long term, but until recently there has been little evidence to support the use of exercise in treating these conditions. Regular exercise has been shown to have many benefits for people who suffer from chronic neck pain. These include improvements in strength, flexibility, and endurance of the neck muscles. Exercise has also been shown to prevent further episodes of pain by improving the mechanical function of the neck and by reducing the physiological effects of stress and depression. It is important that a good exercise regime for neck pain be well supervised and begin with relatively simple exercises, with the intensity and complexity of exercises progressing as the patient’s confidence and abilities grow. There is strong evidence to support the use of specific exercises to treat chronic headaches. These exercises are generally of the muscle relaxation and neck posture variety. It has been shown that there are certain muscles within the neck and base of the skull which, when in spasm, can cause head pain. By performing exercises to relax these muscles, the symptom of head pain can be alleviated. Posture dysfunction of the upper neck and base of the skull has been identified as a significant factor in the cause and perpetuation of chronic headaches. Exercises to correct this dysfunction have been shown to have excellent results in the reduction of head pain.
Importance of good sleep habits
Sleep is a time for the body and brain to recover from the day’s activities. Without enough sleep, muscles can’t be repaired and new ones can’t be built. Often, people with pain are unable to get a good night’s sleep. There are many factors which contribute to this. Pain can be a direct cause of sleep disturbance. Uncomfortable sleeping positions to avoid pain can cause poor sleep and daytime tiredness. Often, a vicious cycle occurs where poor sleep makes the pain feel worse, which in turn makes sleep more difficult. Mixed in with this can be the development of negative feelings towards sleep, where an individual begins to expect a poor sleep and thus condition themselves to do so. An example of this would be a neck pain sufferer feeling that they are unable to sleep without a firm pillow, who then uses the pillow to support their neck but awakes with a headache and aggravated neck pain. In this case, the pillow may not be the main issue. Shoe-horning it in as a pain relieving aid has only served to add further cause to the problem. In addressing sleep difficulties, identifying and correcting the issues causing poor sleep and any unrelated problems that may have developed is essential. Also known as sleep hygiene, several techniques and lifestyle changes may need to be implemented.
